04050095 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �<CONTRAC,TOIL INFOPIMATl'I
s ,. •.�:
BOILDING ADDRESS: SPEEDY ROOTER PLUMBING PE"Mr`N904:050095
OWNER'S NAME: PERMIT ISSUE DAM
CAMILLA NILES
ONE: SANITARY NO, CONTROL NO.
(408) 234-8134
ARCHITEC AINGINEER: BUILDING PERMIT INFO
_ BLDG ELECT PLUMB MECH
Y O z LICENSED CONTRACTOR'S DECLARATION O O
I hereby efforts that 1 am licensed under provisions of Chapter 9(commencing Job Description
n� with Slf n7gIU)foe�f Diviuon3of dta Susi sand Profealom Code.and myliccnde is
y�y„ manor d9 IY t3 Lte WATER MAIN REPLACEMENT
t Li
on.G De Co.DECO
ARCHITECTS CTS DELLA ON
r understand my plans Shall M uatl u public nxmru
3 in f
u.� Licenicd Professional
OWNER-BUILDER U.,,fr DEC CmilraON
n o I Minty alarm o n I am cacmpr from Ibe Comms;Cm :License.,c taw for my
0 0 follwhich
moll a Perm(Seit
Rn I.S.Business ad improve,
demolish.at AnY ehy m wuure
$� which mgoire a e,als m uinst he alma improve,h remitsm mash any ned statement FIY�' poor to its iaeu ed purssuntin in the of for Succonlosnur'su Das Law(tstemem
p athat(commecingwitpunuammtheofDivision
ivio�oflMConlraessandendelJW(Code)or Sq.Ft. Floor Area Valuation
y 'at IM is examwith Section71100)and the
Divisia or de the aged Business and Professions Code)or
Net he is cacmpr neertfrom and the bait for des alleged exemption.Any violation or
SeNon 7071.5 by any applicant for a permit Subjects the applicant to a civil peony of 3 5UflN3 Oer0 0 Occupancye
not mare than Bre hundred dollars(M).
�YP
❑1,a owner of the Property or my employcea with wages as their in compensation.
will do the work,and Ne Structure is not intended or offend for sale(Sec.7044.Business
Slid Profa.Wons Code:The Contactors Licerue Law docs not apply m an owner of Required Inspections
pmpeny who builds or improm thereon,and who does such wart himseHor through his
own employees,provided Thal such improvements an not intended crnWrad for ale.If,
however.the building or improvement hisold within one year of compichim.the owner,
Wilder will have the burden of proving that he did not build or improve for purpose of
ate.).
❑h as owner of the property,am uclusively contracting with limned contractors to
construct Ne project(Sec.7044.Business and ProRssions Code:)The Contacmr's Li- .
came law does not apply to an owner of proper who builds or improve thePaon,and
who contracts for such projects with a contractor(s)[handed pursuant o the Contractors
Ljccn Lew.
m
]lacacmpr under Sec. ,B&PC for Nis moon
wool Data
WORKER'S COMPENSATION DECLARATION
1 hereby aNrm under penalty of perjury one of me following dreamers:
I have and will maintain a Certificate ofCc mem m self-insure for Workers Compere
137M
ion,as provided for by Section 37M of the tabor Code,for the pedarmmca of the
rk for which this permit is issued.
1 have and will maintain Workers Competwtion Immune,a inquired by Section
of me labor Code.for nee performance of the work for which this Permit is issued.
y Worker Ccapemet'on imurarmc enioandPolicynumberam:
m r. Polity No.:
CERTIFICATE OF EXEMPTION FR ORKERS'
COMPENSATION INSURA CE
(This Section need not M completed If the permit is for one hundred dollars(SIM)
or less
1 col IS,that he pe unnance of the work for which this Permit is issued.I shall not
em by any re ninay ane nes so become subject to the Workeri Compemalton
V sof Calf
kp i t
N ANT:If. term s Cenificete of Exemption,you should
.1 hlecl m the Woholi o penadon provisions of the labor Code.you must
wJ O fa m comply wine such provisions or this permit shall W accrued Pavokc4.
r y CONSTRUCTION LENDING AGENCY
l hereby affirm mat then is a construction lending agency for the performance of
!Y> the work for which this permit B issued(Sm.5097.Civ,C.)
Q Landers Name
IS,Q z Lender.Add.
U Q i certify Nal I have mad Nie application and soon that the above Information is
U.F•' comet.l agree in comply with all city and county andinantts and SUM laws Palating m
QU building construction,and hereby cuthoria repmsentedim of this city in color upon the
tT1 red pmpcnY for impaction purposes
�^ agree to ave,indemnify and keep harmless the City of Centeno.against
IMblliti .1 gmcnsampunedeape.which mayin anywayaccmn agemeaaid City
U in co Sec ce of the granting of this permit.
4 SOP C GUN Save
AND WILL COMPLY WITH ALL NON-POINT Issued by: DaPinstalled.
�� Re-roofs
ign umn Applicant/Contracmr ale HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant car fumrt building occupant smrc orhandlc heaardous material
a defined by the Cupertino Municipal Code,Chapter 9.12,and IM Health and Safely
otic ❑Yesecusen ss552UI? tlNnAll roofs shall be inspected prior to any roofing material
> If a roof is installed without first obtaining an inspection,I agree to remove
Will me applicant or future building occupant use Nuipmem ar devices which
it hanmdous air cmtsminants a defined by me Bay Ama Air Quality Management all new materials for inspection.
District]
❑Yes No
Litatic,rical thehaamousm=dalsmquimmenuunderCMpur&95ofdteGlifor-
me th& 'ally Cada Sccdoa25505,25555md25534.lundcound thdifthc Wilding
d not cur I haw a tanam,that It is my nespamibilily to notify the cempam of the
req Immense ' h ustMmct pdorm issu ofa Ccrtine¢orOccu ey. Signature of Applicant Date
e All roof coverings to be Class "B"or better
Owner or euthomcJ agentg
aCOF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
11UPEkTINO
Building Department
JOB ADDRE • PERMIT #
113Lt s o-vv c sb ON o S a o S
OWNER'SN in, (..(�t_v,�. PHONE S45-c%(.qz>
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing see-uv y Q_zoTtwl
Roofing
Septic Tank
Sheet Metal
Sheet Rock
ile
5n —
Owner/ actor Signature Date
r
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
35c� -,�I o6v 5I
Building Address:
1161 SYI�^P16 Ct;VSs IN
Owner's Name: Phone#:
NkLCrS 4 5S5-C�640
Contractor: Phone: License#:
SFC W I 12007U,11i -1 Ci q .�
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ umb ❑
Job Description:
vV vr\A M VLWc,wc.W- of A,\dw-f—
Residential ® Commercial ❑
Cost of oject: 4�
II"1S
i Y• i
AnDficable Fee ID Fee Description Fee Group
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFD{TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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